Irritable bowel syndrome (IBS) is a very common disorder, which affects as many as six million Canadians with symptoms that include abdominal pain, bloating, constipation, and/or diarrhea. IBS represents 12% of all patients seen by primary care physicians and about half of the patients seen by gastroenterologists. About one third of patients with IBS primarily suffer from diarrhea. See irritable bowel syndrome fast facts for a quick look at IBS.
The definition of chronic diarrhea is having three or more bowel movements per day for three or more months. Diarrhea could either be multiple solid bowel movements or be watery or explosive in nature. This may, or may not, be associated with loss of bowel control (fecal incontinence). In fact, some patients need to wear adult diapers (incontinence pads) to avoid embarrassing leakage scenarios. Classically, these patients know the location of every bathroom wherever they go, a condition known as bathroom mapping.
Frequently, chronic diarrhea not related to specific conditions such as Crohn’s or celiac disease, is attributed to irritable bowel syndrome and, as such, physicians employ conventional therapies such as anti-spasmodic and anti-diarrheal agents. Success of these therapies varies greatly on a patient-by-patient basis.
Recent research suggests that some patients diagnosed with IBS and suffering from chronic diarrhea might be misdiagnosed. A proposed new syndrome, Habba syndrome, sheds some light on the origins of some cases of diarrhea and offers symptom relief for these chronic diarrhea sufferers.
So what is Habba syndrome?
Habba syndrome is an association between chronic diarrhea and a dysfunctional gallbladder, which produces an abnormal amount of bile. This condition is responsible for symptoms that are usually very distressing and may cause social embarrassment and interference with daily activities. Weight loss may result because patients avoid eating for fear of the pain and consequences of chronic diarrhea. Some are even homebound from fear of social embarrassment. Habba syndrome diarrhea classically occurs after eating (post-prandrial) and is rarely nocturnal, unless the patient had a meal close to bedtime. It is not associated with internal bleeding, unless it comes from irritation of the rectal area, which would show up as bright red blood on or around the stool.
The following symptoms are not typical of either IBS or the proposed Habba syndrome, and if you have these, you should alert your physician:
- rectal bleeding
- unplanned weight loss
- family history of colon cancer
What are the primary symptoms of this syndrome?
- Post-prandrial diarrhea (varying from simple urgency to incontinence), associated with fear of eating to avoid diarrhea
- Dysfunctional gallbladder as determined by radiological testing
- Failure to respond to standard IBS therapy
- Favourable response to bile acid binding agents
What should you do if you have these symptoms?
Check with your primary care physician or gastroenterologist, who will examine you and determine if further diagnostic testing is necessary. Testing may include stool analysis, lab work, x-rays, and colonoscopy. Further testing to rule out malabsorptive conditions, inflammatory bowel disease (ulcerative colitis and Crohn’s disease), and cancer may be required.
To confirm a diagnosis of Habba syndrome, doctors look at gallbladder function by using a nuclear medicine x-ray study known as a DISIDA scan, with CCK injection to evaluate the ejection fraction of the gallbladder. This indicates if the gallbladder is working properly.
What is the treatment for Habba syndrome?
Since the basic pathology of the syndrome is inappropriate bile in the gastrointestinal tract related to a dysfunctional gallbladder, therapy focuses on changing the constitution of bile acids to decrease their diarrheal effect. Agents that bind bile acids are proven as safe, effective, and inexpensive. Some are available in generic forms.
Patients should take these agents half an hour prior to meals to maximize the effect of binding to the bile acids. In the original publication describing this syndrome, patients treated with cholestyramine (Questran®) responded very favourably, usually within days of starting therapy.